Record Release Form

I hereby authorize

Street Address

Phone Number

Fax

To release the records of

Date of Birth

SS #

Street Address: 753 South Washington, Fredericksburg, TX 78624
Phone: 830-992-3396 Fax: 830-992-3538

This disclosure of records authorized herein is required for the following:

and such disclosure shall be limited to the following information:

This consent is subject to revocation by the undersigned at any time except to the extent that the disclosure is already been made.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient's or guardian's signature

Witness Signature

Date

Your information will be encrypted.